Description of clinical pharmacists reported interventions to prevent adverse drug events among patients with cardiovascular disease in Qatar

Background Unidentified drug-related problems (DRPs) can cause negative health and economic consequences if not addressed appropriately. The literature revealed that interventions conducted by clinical pharmacists can positively impact patient safety and treatment outcomes. The role of clinical pharmacists has been continually growing while posing significant improvements in the provision of healthcare. Objective To describe clinical pharmacist interventions in hospitalized patients with cardiovascular disease (CVD) in Qatar. Methods This is a retrospective analysis of clinical pharmacist interventions documented in an electronic patient medical database. Data were retrieved from three date ranges and comprised demographic information, interventions, medical wards, drug therapy, and medical disorders. Clinical pharmacist interventions were categorized using a standardized intervention reporting sheet from the medical database in the hospital. Results A total of 845 interventions relating to 262 patients were included in this study. The study population consisted mainly of males (n = 158 [60%]) with an average age of 61 years (SD ± 13.05). The leading documented interventions were the addition of medication (n = 278 [32.9%]), medication discontinuation (n = 196 [23.2%]), and an increase in medication dosage (n = 155 [18.3%]). A similar trend was observed throughout all subcategories investigated in this study, that is, interventions according to age, ward, and gender. An exception to the common trend was demonstrated in the emergency department, where medication discontinuation was the most frequent intervention. The classes of medications with the highest frequency of reported interventions included cardiovascular medications, followed by endocrine and hormonal agents (n = 393 [46.51%] and n = 159 [18.7%], respectively). Conclusion Interventions conducted by clinical pharmacists have proven to have a positive impact on patient safety in addressing and resolving DRPs. Healthcare systems may benefit from future efforts directed toward studies of a prospective nature while developing a unique indicator of the validity and precision of documented interventions.


ABSTRACT
Background: Unidentified drug-related problems (DRPs) can cause negative health and economic consequences if not addressed appropriately.The literature revealed that interventions conducted by clinical pharmacists can positively impact patient safety and treatment outcomes.The role of clinical pharmacists has been continually growing while posing significant improvements in the provision of healthcare.Objective: To describe clinical pharmacist interventions in hospitalized patients with cardiovascular disease (CVD) in Qatar.Methods: This is a retrospective analysis of clinical pharmacist interventions documented in an electronic patient medical database.Data were retrieved from three date ranges and comprised demographic information, interventions, medical wards, drug therapy, and medical disorders.Clinical pharmacist interventions were categorized using a standardized intervention reporting sheet from the medical database in the hospital.Results: A total of 845 interventions relating to 262 patients were included in this study.The study population consisted mainly of males (n = 158 [60%]) with an average age of 61 years (SD ± 13.05).The leading documented interventions were the addition of medication (n = 278 [32.9%]), medication discontinuation (n = 196 [23.2%]), and an increase in medication dosage (n = 155 [18.3%]).A similar trend was observed throughout all subcategories investigated in this study, that is, interventions according to age, ward,

INTRODUCTION
Pharmaceutical care highlights the crucial importance of practicing safe and effective therapeutic patient care.Notably, patient safety is one of the most essential aspects of a healthcare system, as recognized by numerous international organizations. 1,2Efforts by healthcare professionals, primarily clinical pharmacists, have been dedicated to ensuring the safety of patient management while aiming to identify drug-related problems (DRPs), reverse medication errors, and avoid adverse drug reactions (ADRs) or adverse events (AEs). 3,4A DRP is defined by the Pharmaceutical Care Network Europe Association as an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes. 5In addition, there is a wide array of DRPs that may be observed in healthcare systems, where the American Society of Health-System Pharmacists acknowledges eight types of DRPs, including ADRs, medication errors, drugs without indication, failure to receive medication, drug interactions, noncompliance, untreated indications, and drug poisoning. 6,7rthermore, DRPs may escalate into serious health issues such as the possible increase in the length of hospital stay, intensive care unit (ICU) admissions,

Study design and setting
A retrospective analysis of CPIs documented in an electronic patient medical database (Cerner) at the Heart Hospital (HH), Hamad Medical Corporation (HMC), Doha, Qatar.This hospital setting is known as the leading contributor to the secondary and tertiary healthcare provision of cardiology services, with 139 beds, in Qatar.The CPI is defined as "any action by a pharmacist that directly resulted in a change to patient management or therapy. 27" The respective interventions are routinely documented in an electronically embedded intervention sheet found in Cerner.

Sample population
CPIs conducted in any adult patient admitted to HH and reported in Cerner during the date periods between March 1 st and March 31 st , 2018; between July 15 th and August 15 th , 2018; and between January 1 st and January 31 st , 2019 were considered eligible to be included in this study.Notably, only CPIs approved by physicians were included since clinical pharmacists merely place recommendations to conduct an intervention; a physician's approval is required so that the intervention is executed and patient care is altered accordingly.The CPIs that were conducted by operational pharmacists were excluded.The frequency and types of CPIs were described according to several subgroups, including, age group, gender, class of medications, and medical wards.Age groups were classified as adult (less than 65 years of age) or elderly (65 years of age or older).

Data extraction and synthesis
Demographic data relating to the patient population as well as the description of CPIs were extracted from a standardized CPI reporting system in Cerner and recorded in an electronic data collection sheet.The CPI categories and their subtypes were obtained from the standardized sheet, including (1) involved medication, (2) pharmacological class, (3) route of administration, (4) prescriber response, and (5) intervention type: appropriate therapy, contraindication/safety, dosing/administration, drug interaction, duplicate therapy, non-formulary, drug information, medication reconciliation, and incomplete prescription.When data is not available through the CPI reporting system (e.g., patient or medication-related information), the medical records for the respective patients would then have to be reviewed in order to obtain the data.Two members of the research team evaluated all the extracted intervention details.

Data analysis
Data analysis was completed using IBM Statistical Package for Social Sciences (IBM SPSS Statistics, Version 24.0;IBM Corp., Armonk, NY).Continuous variables were presented as means ± standard deviation (SD), while categorical variables were displayed as frequencies and percentages.

Description of study population
A total of 262 patients in the HH were enrolled in this study with a total of 845 reported CPIs, taking place across 3 months within an 11-month period (March 2018 to January 2019).The majority of the patients were male (n = 158 [60%]) and the mean age of the study population was 61 years.As reported in Table 1, more than (n = 197 [75%]) of the patients were Arab and were admitted to the inpatient general cardiology unit.Furthermore, Figure 1 highlighted the most common active cardiovascular medical disorders for which CPIs were reported: acute coronary syndrome (ACS) (n = 287 [33.96%]) and heart failure (n = 223 [23.79%]).The most frequently occurring active medical disorder in the male population was ACS (n = 169 [59%]), while heart failure was the highest amongst the female population (n = 131 [58%]).Description of clinical pharmacists reported interventions to prevent adverse drug events as well as "increase in medication frequency"

Description of CPIs
The  commonly reported amongst the adult and elderly (above 65 years of age) as well as the male and female subgroup populations (Figure 2 and Table 3, respectively).Particularly, this CPI was reported more frequently in the male population as compared to CPIs took place between July and August 2018, and 107 (12.6%)CPIs were reported in January 2019 (Table 1).The occurrence of the various types of CPIs was investigated according to subcategories where "addition of another medication" was the most     3).Both classes were more frequently present in CPIs conducted in the adult population as compared to the elderly population (Table 5).

Description of CPIs according to hospital ward
General cardiology units Critical care units A total of 40 CPIs were conducted in critical care units.Most of the CPIs were reported for male and elderly patients (Tables 5 and 6).A similar trend of frequently occurring CPIs was demonstrated in the critical care unit as that observed with general cardiology (Figure 4).Only two CPIs were documented for each "addition of a lab test," "decrease in medication dose," and "switching to alternative medication," while one intervention was reported for "addition of a serum level" and "decrease in medication frequency."care units, with "addition of another medication" being the most commonly reported type of CPI, the ED demonstrated that "discontinuation of a medication" was the most occurring CPI, followed by "addition of another medication" (Figure 4).As seen in all hospital settings, most CPIs were reported in male and elderly patient populations.With regards to CPIs under classes of medications, the same classes were frequently observed in both the general cardiology and ED units, where cardiovascular drugs were the highest, followed by endocrine and hormonal agents (Table 6).

Heart failure clinic
The clinical pharmacists practicing in the heart failure clinic documented a total of 18 CPIs.In this case, however, the majority were observed in female and elderly patient populations.The commonly occurring CPIs in this setting demonstrated a similar pattern to those observed in the critical and general cardiology settings, with "addition of another medication" being the highest amongst all the CPIs (n = 8 [44%]) (Figure 4).Similar to the critical care units, the most frequent classes of medications with reported CPIs were cardiovascular drugs and blood derivatives and immunoglobulins; n = 11 (61%) and n = 3 (17%), respectively (Table 6).

DISCUSSION
This is the first study of its kind to be conducted in a specialized cardiology hospital in Qatar, aiming to describe and analyze interventions placed by clinical pharmacists.The most prominent finding that was observed in this study was that the addition of another medication was the most frequently occurring CPI amongst the total of analyzed CPIs, followed by discontinuation of a medication.][30] It is worth mentioning that the majority of previously published studies did not consider the addition of medications as part of the categories of interventions. 18,21,23While several studies demonstrated the occurrence of interventions relating to the alteration of drug therapy, such studies were conducted in outpatient settings, with examples demonstrated in the Kingdom of Saudi Arabia, the United Arab Emirates, the ambulatory care setting in Qatar, and the community pharmacy setting in the United Kingdom. 19,25,27,30Such therapyaltering interventions significantly highlighted the role of the clinical pharmacist since pharmacists are known to significantly contribute to the identification of medical conditions that have not been receiving adequate treatment or conditions that have not been diagnosed previously and, hence, require necessary treatment as recommended by the clinical pharmacists. 29,30Furthermore, the second most reported CPI in this study was related to the discontinuation of unnecessary medications, which was considered consistent with findings reported in numerous studies that investigated CPIs in several patient settings. 25,27,28Considering that pharmacists possess specialized knowledge of medications and their indications, such results were highly anticipated and were consistent with the current study.Moreover, given the nature of the heart hospital setting investigated in this study, it was expected that the majority of the medical conditions would be of a cardiovascular nature.Hence, the most commonly witnessed class of medications for which CPIs were documented was cardiovascular medications.This did not directly align with findings from other studies since this was the first study to outline CPIs in a specialized heart hospital setting.Nevertheless, previous studies demonstrated that cardiovascular agents were frequently the second most recorded medications for which CPIs were conducted, seeing that cardiovascular disease is one of the leading medical conditions in the world, with the most common medications being anti-infective agents. 31,32pecifically, from this pharmacological class, the CPIs were most frequently associated with bisoprolol, warfarin, and aspirin, where the majority of CPIs reported under this class were "addition of another medication," followed by "discontinuation of a medication," and "increase in medication dose."In the case of aspirin, it is usually not prescribed appropriately for secondary prevention of events, as recommended by certain guidelines such as the American Heart Association (AHA) Guidelines, and, Description of clinical pharmacists reported interventions to prevent adverse drug events crucial role of clinical pharmacists in conducting medication reconciliation at the time of admission and discharge, where this is the typical practice demonstrated in HH and all hospitals under HMC, and this is further supported by the fact that the most frequently occurring CPIs were attributed to the addition or discontinuation of medications as well as dosing adjustments.This is essential since it immensely aids in the therapeutic regimen planned for the patient during their hospital stay, and it is considered one of the most effective strategies to ensure that the appropriate medications are considered while avoiding any consequent patient harm and unnecessary monetary spending. 35his study involves several limitations.The retrospective nature of the study allows for a high chance of missed data pertaining to the CPIs as well as missing data about the general population.Consequently, studies that are prospective in nature are recommended.Also, the CPIs included in the study were not subject to content quality appraisal since it was assumed that the content verification would be completed by the clinical pharmacist placing the intervention and the prescribing physician who approved it. 36Furthermore, the female and male populations were uneven, noting that this may be attributable to the nature of the country's population, where the most recent statistics report that males comprise more than 70% of Qatar's population. 37Despite the presence of the mentioned limitations, this study reports considerably significant findings relating to the contribution of the clinical pharmacist in patient management in the cardiology setting, enhancing medication safety, and avoiding patient harm.This study also resulted in significant economic benefits in terms of cost savings and cost avoidance, as previously reported in our study, 38 amounting to QAR1,595,948 (USD 438,447) per 3 months.

CONCLUSION
This study highlighted a detailed overview of CPIs documented in the specialized HH, HMC, Qatar.Key findings revealed that the clinical pharmacists' efforts in providing pharmaceutical care had posed a significant contribution to patient management, with presumed positive value for patient safety.Further focus may be beneficial when targeting the for this reason, clinical pharmacists typically suggest the addition of aspirin to the patient's regimen. 33For warfarin, CPIs would be related to dosing adjustments since this is highly common with this agent, and doses are susceptible to change based on the relative international normalized ratio (INR) readings.It is an important role of the clinical pharmacist in this setting to monitor INR levels and associate them with the relative warfarin dosing regimen, in addition to performing cardiovascular risk assessments for patients with prior cardiovascular events in order to recommend secondary prevention regimens. 26,33Notably, only one CPI suggested the addition of a serum level under this pharmacological class, and this also suggests the role of the clinical pharmacist in identifying the important serum levels required to monitor the effects of medications.Additionally, the second most commonly observed pharmacological class was that of the endocrine system and hormonal agents, where the medications that were frequently documented were insulin, glargine, and atorvastatin.The highly reported CPI under this class of medications was "increase in medication dose," followed by "addition of another medication."This finding was expected to be observed with a medication such as insulin glargine since the majority of diabetic patients who are hospitalized tend to show uncontrolled blood glucose control during admission due to stress and changes in diet and therapy regimens.In such cases, the role of the clinical pharmacists is significantly highlighted, where they would monitor the blood sugar levels on a daily basis and, therefore, implement relevant recommendations with regards to increasing the dose of insulin in order to achieve adequate control.
Similarly, the documentation of atorvastatin in the CPIs relating to this pharmacological class could also be related to the primary and secondary prevention of cardiovascular events.An additional significant result in this study was observed in the data pertaining to CPIs in the ED, in which the most frequently occurring CPI was related to the discontinuation of a medication, and this was seen as an inconsistency with previous studies that analyzed CPIs in the ED. 10,34Such studies reported that dose modification and inquiry of drug information were more abundantly observed.Furthermore, it is worth highlighting the

Figure 1 .
Figure 1.Frequency of pharmacist interventions according to active medical disorders.

Figure 3 .
Figure 3. Classes of medications according to gender.

Figure 4 .
Figure 4. Types of interventions according to ward.
Description of clinical pharmacists reported interventions to prevent adverse drug events

Table 1 . Characteristics of the study population.
CPIs were reported based on a classification of the types of interventions listed inTable 2. The most abundant CPI documented was "addition of VOL.2024 / ART.27 Description of clinical pharmacists reported interventions to prevent adverse drug events

Table 2 . Classification of interventions.
Figure 2. Types of interventions according to age group.VOL.2024 / ART.27 Description of clinical pharmacists reported interventions to prevent adverse drug events

Table 6 . Classes of medications according to ward.
VOL. 2024 / ART.27Description of clinical pharmacists reported interventions to prevent adverse drug events